Notification of ownership of radiation equipment - Form A

Every person who becomes an owner of an x-ray machine, a source that is not an x-ray machine, or laser equipment shall complete and deliver Form A to the board within 30 days of becoming an owner. Please submit a separate registration for each piece of equipment.

This information is being collected for the purposes of administering and enforcing the Workers’ Safety and Compensation Act and is collected under the authority of that Act and the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the Privacy Officer at WSCB at the above listed address or at (867)667-5645 or 1-800-661-0443.

Owner of the Equipment

Radiation Equipment Location

Physical location of the equipment
Provide information about all radiation equipment which is kept at the same location.
Make Model/Serial No. Date installed at this location Function*
*Function options include: Therapy, Radiography, Conventional Fluoroscopy, Remote Control Fluoroscopy, Mammography, Mobile Dermatology, Training/Instruction, Demonstration, repair, installation, Industrial progress control, Analytical (Diffraction) Testing, Other.

Owner of Premises where the radiation equipment is located

Person Responsible for safe use of equipment

Signature, consent, declaration

hereby notify the board of ownership of radiation equipment as required under section 3 of the Radiation Protection Regulations.

Separate notification is required in respect of each location.